developing interoperable ehr: maximizing quality of care gregory j downing, do, phd office of the...
TRANSCRIPT
Developing Interoperable Developing Interoperable EHR:EHR:
Maximizing Quality of Maximizing Quality of CareCare
Gregory J Downing, DO, PhDGregory J Downing, DO, PhDOffice of the SecretaryOffice of the SecretaryDepartment of Health and Human ServicesDepartment of Health and Human Services
July 13th, 2009July 13th, 2009
What Does an Interoperable EHR Provide?
• Information Sharing– Continuity of Care– Privacy– Evidence Base– Clinical Decision Support (CDS)
Platform
• Effectiveness Assessment
– Quality Measures• Regional vs. Nation-wide
• Public Health– FDA Sentinel
• Adverse event reporting and safety alerts
– CDC• Biosurveillance and safety
alerts
Guidelines &
CDS
Quality Measures
Health Care Delivery
Clinical Research
A Learning Health Care
System
Etheredge LM. A Rapid-Learning Health SystemHealth Affairs, 2007
1
Model EHR Deployment for Information Management
• Veteran’s Affairs and Indian Health Service– VistA (Veterans Health Information System and Technology
Architecture)
• Private sector healthcare systems– Kaiser Permanente– Geisinger– Harvard Partners
• National Health Information Network (NHIN)– Regional Health Information Organization (RHIO)– Health Information Exchange (HIE)
• Distributed Ambulatory Research in Therapeutics Network (DARTNet)– AHRQ and American Academy of Family Physicians
• SOA Platforms (e.g. MS HealthVault, GoogleHealth, Dossia) 2
Can Information Management Improve Quality of Care?
3
• Current ability to measure and compare health care quality
• How much medical practice is actually evidence-based?– Numbers vary greatly on geography and specialty– Range from 10-80%
• Policies about evidence development– The Medicare Evidence Development & Coverage Advisory
Committee (MEDCAC) was established to provide independent guidance and expert advice to CMS on specific clinical topics.
EHRs and the Evidence Base
• EHR data can be used for research to develop evidence-based guidelines
• Guidelines can be supplied to the clinician at the appropriate time through clinical decision support (CDS)
• Quality of care can be measured through improved health outcomes
4
EHR Data for Evidence-Based Medicine
• US Preventive Services Task Force:
– Level I: Evidence obtained from at least one properly designed randomized controlled trial.
– Level II-1: Evidence obtained from well-designed controlled trials without randomization.
– Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
– Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
– Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
EH
R-P
rovi
ded
Dat
a
5
Academia, GovernmentBiopharmaceutical
-SponsoredData Acquisition,
Analysis
Publications
RegulatoryReviews
Protocol-driven Clinical Trials
Basic Clinical Research
Investigator-Sponsored Data Acquisition,
Analysis
Healthcare Delivery
Patient Information
Insurance Claims
Developing and Evidence-Base with EHR Data
Guideline Development
6With permission: Kush, R; CDISC; 2009
EHR Clinical Research Value/Use Case
• ANSI convened an EHR Clinical Research Value Case Workgroup for prioritization of clinical research use cases.
• Core Research Data Element Exchange – Identify core research data elements
– Identify processes for transacting these data appropriately
• EHR Ability to Provide Data for Guideline Development and Quality Measurement– Establishes standards for interoperability
– Enables information exchange
7
Comparative Effectiveness
Accelerate the development and dissemination of research assessing the comparative effectiveness of health care treatments and strategies,
through efforts that:
1.conduct, support, or synthesize research that compares the clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders, and other health conditions; and
2.encourage the development and use of clinical registries, clinical data networks, and other forms of electronic health data that can be used to generate or obtain outcomes data
• AHRQ - $700M• NIH OD - $400M• HHS - $400M
•EHRs support comparative effectiveness research as a source of aggregated data on interventions and outcomes
8
CDS Roadmap Osheroff et al., 2006JAMIA
Clinical Decision Support
• EHRs provide a platform for clinical decision support to promote adherence to evolving evidence-based guidelines.
– Clinical Decision Support (CDS) • computerized alerts and reminders• clinical guidelines• order sets• patient data reports and dashboards• documentation templates • diagnostic support• clinical workflow tools
– Three pillars of CDS• Best knowledge available when needed• High adoption and effective use• Continuous improvement of knowledge and CDS methods
• CCHIT certification for CDS
9
Translation of Guidelines into Executable Actions
10
www.intracarecorporation.com
IHS Resource and Patient Management System
11
http://www.ihs.gov/CIO/EHR/
IHS RPMS – Patient Record
12
IHS RPMS iCARE – Population Management Tool
13
Challenges of Planning in Times of Uncertainty
• Technology – massive deployment across diffuse networks and systems in widely diverse platforms and states of readiness
• Diverse users with widely variable skill sets and workflows– clinicians, nurses, PA– primary care, specialty care
• Variability of evidence base, multiple guidelines– conversion of machine and human readable information into executable
actions
• Moving target of reimbursement models for patient care• Incentives for physician and health system EHR adoption• Performance-based practice measures• Application of EHRs in measures of quality performance
IT
Human Factors
Gov’tPolicy
14
